A New Zealand coroner has found that systemic failures in mental health follow-up care contributed to the death of Dunedin poet Ian Loughran, who died by suicide in July 2021. Coroner Mary-Anne Borrowdale’s report concluded that Loughran was deprived of his best chance at recovery after he was discharged from a mental health ward without a clear medication plan or integrated community support.
Coroner Findings on Systemic Failures
Coroner Borrowdale’s inquest, released Wednesday, identified significant gaps in the care provided to the 55-year-old by Health New Zealand. Loughran, who lived with bipolar disorder, had been admitted to Wakari Hospital twice in 2021. Following his second discharge, he went 11 weeks without specialist follow-up.
The coroner stated that clinical records describing Loughran as "AWOL" were misleading. Instead, the evidence showed that the North Community Mental Health Team (NCMHT) failed to make contact with him, despite his recent 23-day inpatient admission. "It would be more accurate to state that EPS [the emergency psychiatric service] avoided having any contact with Mr Loughran," the coroner noted in her findings.
Medication Management and Discharge Protocols
A primary concern raised by the inquest involved the lack of continuity in medication. During his first hospital stay, Loughran responded well to an injection of depot olanzapine. However, he was discharged without a plan for his next dose due to missing paperwork.
The coroner emphasized that the discharge summary provided to Loughran and his GP lacked essential information, including:
- Clear advice on managing medication.
- Warning signs of a potential relapse.
- Specific protocols for accessing crisis support.
According to the coroner, the lack of integrated follow-up made a rapid deterioration in his mental health "virtually assured."
Health New Zealand’s Response
Following an internal critical incident review, Health New Zealand initially proposed implementing mandatory verbal handovers between inpatient and outpatient consultants. However, the agency later deemed this measure "not achievable."
Coroner Borrowdale criticized this reversal, stating the response provided "no reassurance at all" that similar errors would not happen again. She described the one-to-one handover between clinicians as an "indispensable requirement" for patient safety.
Recommendations for Mental Health Reform
The coroner issued 12 formal recommendations to Health New Zealand to address these lapses. These include:
- Timely Documentation: Ensuring discharge summaries are comprehensive and tailored to the individual patient’s needs.
- Accountability: Clearly identifying which senior clinician holds responsibility for a patient’s care post-discharge.
- Medication Protocols: Establishing formal, written protocols for medication clinics to ensure direct communication between psychiatrists and community teams when delays occur.
Loughran was a prominent figure in the Dunedin literary scene, known for his work as a performance poet, playwright, and comedy writer. While the coroner determined his inpatient hospital treatment was satisfactory, she concluded that the "disconnectedness" of his transition back to the community ultimately failed him.
If you or someone you know is struggling with mental health, help is available. In New Zealand, you can call or text 1737 to talk with a trained counselor for free, 24 hours a day.